1Patient Safety & Clinical Pharmacy Services Collaborative Rebecca CheekDirector of PharmacyWhite House Clinics
2Questions to Run OnHow can you implement Clinical Pharmacy Services at your site?Do you have a method in place to track Adverse Drug Events (ADE’s) and potential Adverse Drug Events (pADE’s)?
3PSPC Similar to other HRSA sponsored collaboratives All Teach, All Learn environmentStarting 3rd year in October 2010White House Clinic has been involved since the beginning-August 2008
4Our Collaborative Team Clinical Pharmacy Service Providers at the Primary Health Care HomeBecky Cheek, PharmDPharmacy DirectorCollaborative LeadSharon Davidson, PharmDSteven Wagers, PharmDOther Providers at thePrimary Health Care HomeMelissa Zook, M.D.Family PhysicianMedical DirectorSandra Dionisio, M.D.Internist
5PSPC Collaborative AIM To Save and Enhance thousands of lives each year by:Achieving optimal health care outcomes andEliminating Adverse Drug Events throughIncreased Clinical Pharmacy Services for the patients we serveThe Goal of Collaborative Services is to:Improve patient safetyImprove patient health outcomesIntegration of cost-effective clinical pharmacy services
6Our PSPC Aim StatementWhite House Clinics will strive to provide clinical pharmacy services to high-risk patients in an effort to decrease adverse events while encouraging those patients to become active partners in the management of their health condition.
7What are Clinical Pharmacy Services? CPS are patient-centered services that promote the appropriate selection and utilization of medications through:Medication access*340b formularyRecommending generic alternativesPatient Assistance ProgramsPatient counseling *Rx pick-up (required by OBRA-90)Phone callsMedication Therapy Management (MTM)*Poly-pharmacy managementRecommendations given to patient or providerChanges to therapy after DUR/ADE
8CPS Services cont. 5. Drug Information Services to Patients* 4. Preventive Care ProgramsBMI or blood pressureImmunizationsDrug Information Services to Patients5. Drug Information Services to Patients*Drug information leafletsDisease state pamphletsMedication Reconciliation ServicesHaving 1 accurate medication list
9CPS services cont. Retrospective Drug Utilization Review* 7. Provider Education*Pharmacist provides evidence based drug information to providerRetrospective Drug Utilization Review*Review patients on certain meds or with certain disease states to assess quality and safetyDisease State Management*Medications managed to obtain health outcomes and improve safetyLabs ordered and evaluated
10CPS services cont Prospective chart review and provider consultation* Review chart before visit and make recommendations to provider team*Clinical pharmacy services that we provide at WHC
11Why Are We Doing This Work? Increase in multiple chronic conditionsInstitute of Medicine Report: ADEs are leading cause of death and injuryEvery $ spent on a RX = a $ spent on an ADEAging population/chronic disease – leading to high prevalence of poly-pharmacyLack of integration of clinical pharmacy servicesAlignment with HRSA Core Measures
12Key Benefits It’s the Right Thing to Do for the Patients We Serve SaferIncreased and Better Pharmacy ServicesImproved Health OutcomesReduces/Manages Risk – and Risk is IncreasingBuilds on and Takes Prior Knowledge Base and Experience to a New LevelTakes HRSA Collaborative Experiences to the Next Power
13Key Benefits Integrates Services to Maximize Community Health Reduces Inappropriate Use of Poly-pharmacy – Better Medication ManagementHelps Create New Partnerships & Synergies Across Provider OrganizationsExposure to Cutting Edge People and Methods on Quality Improvement, Leadership & Change ManagementOpportunity to be a Part of a Major National Movement in a Rewarding All Teach, All Learn Environment
14Examples of Disease States in Collaborative Diabetes-HgA1CHypertension-blood pressureHyperlipidemia-LDL, triglyceridesAsthma-peak flow, ACT test, controller medsAnticoagulation-INR in rangeHIV
18PSPC Outcomes: Improvements in Health Status 49% improved from health status “out of control” to “under control”Across a range of chronic diseases, using standardized measures — such as A1C levels, blood pressure, LDL, INR ranges, depression scores, and viral loadAverage team improvement through July 2010
19What did we need to do for the collaborative? We needed to choose a Population of Focus (POF)We needed to track ADE’s and pADE’s to improve safety
202% of Patients Can Benefit from CPS on One of the ISMP High-Alert Medications 833,936 pat/yearTotal Patient Population16,284 pat/yearTotal Population of Care that could benefit from CPS315 pat/yr75Total Population of Focus(Anticoagulant Treatment)Current PSPC teams:Even as they’re starting out small, PSPC will have big impact through spread.These numbers show us that we have an opportunity to reach and spread this work to more and more patients.PSPC Population of Focus202020202020
21White House Clinics Improvement Story Population of Focus – Patients receiving Coumadin® (Warfarin) therapy referred to the Coumadin Clinic for anticoagulation managementBaseline data unavailable as no data tracking methods in placeAfter enrolling, developed plan to collect data-manual, EMR template, EMR reports
24High Risk Qualities in POF Panel Medications per Patient – 7 to 8Providers per Patient – 3Largest Safety Issues – Bleeding, Thrombotic EventLargest Health Status Problems – Hypertension, Atrial Fibrillation, Diabetes
25Anticoagulation Management Data %INR values within range (goal )Usual medical care with physician: 29.6%Pharmacist-run Anticoagulation Clinic: 64%Chiquette E, Amato MG, and Bussey HI. Comparison of an Anticoagulation Clinic with Usual Medical Care. Arch Itern Med ; 158:
27Improving Safety and Eliminating Adverse Events Tracking ADEs & pADE ADE – Adverse Drug EventEvents that result in harm or injury to the patient due to medication useExample – Bleeding as a result of Coumadin® (Warfarin) administrationpADE – Potential Adverse Drug EventPotential harm that was identified and avoided with appropriate interventions before reaching the patientExample – Pharmacist catches an allergy to Penicillin and calls the physician to change Amoxicillin to Azithromycin prior to dispensingExample – A Pharmacist notices a duplication of drug therapy (Lisinopril & Ramipril) and intervenes to have one of the medications discontinued before the patient receives the medication
28ADE’s & pADE’s No tracking prior to starting collaborative Through the collaborative many organizations have observed a significant amount of ADE’s and pADE’s due to a lack in tracking dataClinical Pharmacy Services have allowed these same organizations to see a decline in them over time
29How We Should Identify ADEs/pADEs MedicationReconciliationNurse/CMAPhysicianADE/pADEPharmacyPatientER/Hospital
30How Do We Plan On Collecting Data on ADEs/pADEs Information concerning ADE’s and pADE’s will be collected from all available venuesThe PatientThe PharmacyMedication ReconciliationNurse/CMAPhysicianER/Hospital VisitThe data will be evaluated by the provider then entered into an EMR note. This data is easily extracted from EMR for reporting.
31pADE’s and ADE’s for White House Clinic POF pADE’s-low or high INR ranges, drug interactions, interruptions in therapyADE’s-bleeding, thrombosis
32Example of pADE/ADE22 y.o female dx: hypercoagulable state, s/p DVT/PE x5Patient referred by primary care physician after INR had been followed by cardiologist. She could no longer afford to have INR monitored at cardio office. INR at initial visit =1.2. After CPS, we were able to bring her INR in range in a month. She was also determine to conceive. We assisted her with a Patient Assistance Program to get Lovenox and educated her on its use during pregnancy. We also provided counseling and an option to receive Chantix to stop smoking. She has been able to achieve appropriate anticoagulation levels and is now 3 months pregnant. Hopefully, our service avoided potential adverse drug events and actual adverse drug events for the patient and her unborn child.
34Institute for Healthcare Improvement Assessment Scale The Assessment Scale is divided into the following categories:1.0 — Forming team1.5 — Planning for the project has begun2.0 — Activity, but no changes2.5 — Changes tested, but no improvement3.0 — Modest improvement3.5 — Improvement4.0 — Significant Improvement-White House Clinic4.5 — Sustainable Improvement5.0 — Outstanding sustainable results
36PSPC 1 Awards Health Outcomes Management Award Successfully gathered data and reported itLife Saving Patient Safety AwardEstablished systems to identify and prevent ADE’s and have an example of a life threatening ADE that was resolvedPSPC Performance AwardShowed overall excellence during the collaborative
38How did we do it? Better, more focused education for patients Closer patient follow-upBetter data tracking methodsQuality improvement efforts such as Byeth and CHADS2 scoresCollaborative competitionCommunicated data to our providersRequired continuing education in disease state
39The Next Step…PSPC 3Spread of anticoagulation management to other sitesAsthma-working with pediatricianDiabetes-working with Physician Assistant
40What do we need?TimeHard to balance with other duties of a pharmacistStaffHiring a new pharmacistResourcesPharmacy Expansion Grant, provider status for billing services, other fundingSupport of our providers
41Contact InformationRebecca Cheek, PharmDOffice of Pharmacy AffairsHealthcare Communities